A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?

Apply a transfer belt to the client prior to transferring to the stretcher.

Move the client onto the stretcher using a slide board with the assistance of two health care workers.

Have the client roll onto a transfer board and pull the board onto the stretcher.

Move the client's upper body onto the stretcher first.

Answer and Explanation

The Correct Answer is B

Rationale

A. Apply a transfer belt to the client prior to transferring to the stretcher: Transfer belts are used for clients who can stand or provide some degree of weight-bearing support. An immobile 104.3-kg client cannot safely assist with the transfer, making the belt ineffective and unsafe. Using a transfer belt in this scenario increases the risk of falls and caregiver injury.

B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board reduces friction and allows the client to be moved laterally as a single unit, which is the safest method for an immobile client of this weight. Using at least two trained staff members prevents strain and ensures coordinated movement.

C. Have the client roll onto a transfer board and pull the board onto the stretcher: This technique requires the client to participate by rolling, which is not feasible for someone who is immobile. Pulling a transfer board with the client on it creates unnecessary shear forces that increase the risk of skin breakdown. This approach is neither safe nor appropriate for a heavy, immobile patient.

D. Move the client's upper body onto the stretcher first: Moving the client unevenly in sections can cause spinal misalignment and increases the risk of caregiver injury due to poor body mechanics. This technique also creates friction on the client’s skin and may cause discomfort or tissue injury. A coordinated lateral transfer keeps the body aligned and is recommended.

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Correct Answer is A

Explanation

Rationale

A. Puts unneeded clean linens in the hamper: Placing unused clean linens directly into the hamper prevents contamination and maintains medical asepsis. It separates clean items from soiled materials, reducing the risk of spreading microorganisms and preserving a sterile environment for future use.

B. Places soiled linens on the floor: Putting soiled linens on the floor increases the risk of environmental contamination and the spread of pathogens. This practice violates principles of medical asepsis by allowing microorganisms to transfer to the linens and potentially to other surfaces or clients.

C. Holds linens close to the body: Holding linens close to the body can lead to contamination from clothing or skin. Proper medical asepsis requires keeping clean linens away from potential sources of microorganisms to maintain their cleanliness during handling.

D. Shakes soiled linens before placing them in the hamper: Shaking soiled linens disperses microorganisms into the air and onto surrounding surfaces, increasing the risk of infection. Medical asepsis requires handling linens gently and minimizing aerosolization to prevent contamination.

A. Keep the head of the bed flat. B. Hold the client's eyelids closed until they remain shut. C. Apply identification tags to the client's extremities. D. Leave resuscitation equipment and supplies at the bedside.

Correct Answer is B

Explanation

Rationale

A. Keep the head of the bed flat: Keeping the head of the bed flat is not necessary when preparing a body for family viewing. Elevating the head slightly may provide a more natural appearance, but bed positioning does not impact the safety or dignity of the viewing.

B. Hold the client's eyelids closed until they remain shut: After death, the eyes may remain partially open, which can be distressing for the family. Gently holding the eyelids closed until they stay shut helps maintain a peaceful and natural appearance, promoting dignity and reducing potential emotional trauma during viewing.

C. Apply identification tags to the client's extremities: Identification tags are applied for legal and procedural purposes, usually by the mortuary or following facility protocol. While important, this action does not directly prepare the body for family viewing and can be completed afterward.

D. Leave resuscitation equipment and supplies at the bedside: Leaving used resuscitation equipment at the bedside is inappropriate and may be distressing to the family. All supplies should be removed or stored out of sight before family viewing to preserve a respectful environment and maintain dignity.

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A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?

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